Hard data lacking on postdischarge follow-up

“That sits like a lump in my throat,” he said at Internal Medicine Meeting
2016. “I'm not a readmissions guy. I'm a care transitions guy.”

To that end, at his session, “The Evolving Role of Hospitalists in Care Transitions,”
Dr. Greenwald, who is an associate professor of medicine at Harvard Medical School
and Massachusetts General Hospital in Boston, offered attendees a hard look at the
data on a specific area of care transitions: postdischarge follow-up.

He first addressed postdischarge clinics, which he said have historically developed
largely due to problems of access to primary care. For example, “You call up
and after you listen to 10 minutes of Muzak they say, ‘How's 2 weeks from 2019
for an appointment?’” Dr. Greenwald said. “This isn't Primary
Care Practice Bashing 101...but it is the reality most of us face.”

Jeffrey Greenwald, MD. Photo by Kevin Berne

Postdischarge clinics can also be used to improve continuity of care with the hospital
care team, Dr. Greenwald said, for example if a clinician feels a patient needs to
be seen 1 more time because of concerns about asthma. But, he said, “It raises
the question of whether or not these clinics are really just a Band-Aid on a broken
primary care system. And I will tell you as a bit of a spoiler alert, that's in fact
what a lot of the practices that have opened postdischarge clinics have discovered.”

Dr. Greenwald gave a brief overview of the existing literature on postdischarge clinics,
first pointing to a study published in the Journal of General Internal Medicine in 1996 finding a statistically significant difference in ED visits between patients
who visited a postdischarge clinic and those who did not, but no significant differences
in 30-day readmissions, length of stay, or mortality.

A more recent study published by the Journal of Hospital Medicine in 2014 looked at a primary outcome that was a composite of readmissions, ED visits,
and mortality in patients who had a postdischarge visit at an urgent care center,
their primary care physician's office, or a hospitalist-run postdischarge clinic.
No differences were seen between the postdischarge clinic patients and those who saw
their primary care physicians or between the postdischarge clinic patients and those
who went to an urgent care center. When each of the variables was looked at individually,
readmissions were highest in the postdischarge clinic group, and no differences were
seen in ED visits or mortality.

“Their primary outcome was negative. They couldn't demonstrate a benefit,”
Dr. Greenwald said. “At the best, there was sort of a wash.”

Dr. Greenwald pointed out that the literature on postdischarge clinics has traditionally
been complicated because patients are not randomly assigned; they go there because
they can't get into a primary care clinic or there is no primary care clinic available
to them. “They're not random. They may be sicker, they may be older, they may
be poorer, they may be more complicated, they may be from some other socioeconomic
area where they're underserved....Whatever the issue is, these are not apples-to-apples
comparisons,” he said.

He listed the results of his own nonscientific survey of postdischarge clinics, noting
that of the 15 he was familiar with, 40% have shut down. “They've shut down
because they're not financially viable, they didn't have enough patients to go to
them, there were some conflicts with primary care practices around them, etc.,”
Dr. Greenwald said. “The point is at the end of the day a lot of these, which
sounded initially like really good options, failed.”

Regarding postdischarge appointments, “How many of you were told by your resident
that this patient with heart failure, when you were an intern, has to see Dr. Smith
by next Thursday or his head will explode?” he asked the audience. “We
had to have an appointment on the books, and it had to be soon, darn it, because otherwise
you just know this patient's going to fall apart. Well, the problem is the literature
doesn't really corroborate that experience.”

He discussed a study published in the Journal of the American Medical Association in 2010 that looked at the relationship between early physician follow-up and 30-day
readmission among approximately 300,000 Medicare beneficiaries hospitalized for heart
failure. The study assessed hospital-level follow-up rates for 7-day postdischarge
appointments by quartile and found that while the lowest-performing quartile had the
highest readmission rate, there was no difference among the other 3 quartiles.

“So as long as you're not in the bottom quartile, it's OK to be in the second
worst. Well, that's not very reassuring, is it?” Dr. Greenwald asked. Yet another
study published in Medicare Medicaid Research Review in 2014 found no effect of postdischarge visits on 30-day readmissions among approximately
500,000 Medicare patients with acute myocardial infarction, congestive heart failure,
and pneumonia.

Some evidence does suggest that medically complex younger patients may benefit from
postdischarge visits, however, Dr. Greenwald said. In a study published in Annals of Family Medicine in 2015, researchers stratified 44,000 younger Medicaid patients (mean age, 26.5 years)
by comorbidities and calculated a presumptive risk of readmission. In low-risk patients,
expedited follow-up within 7 days made no difference in outcomes. In the higher-risk
patients, however, expedited follow-up did seem to have an effect on readmissions,
he said.

Postdischarge follow-up phone calls are also lacking definitive evidence support,
according to Dr. Greenwald. He pointed to a review done in 2009 by the Cochrane Collaboration
looking at hospital-based telephone follow-up after discharge in 33 studies involving
5,000 patients.

“They couldn't find any evidence of a readmission reduction. But is anybody
surprised?” Dr. Greenwald said. “There are almost no studies where you
do 1 thing and it changes readmission rates. You have to bubble wrap patients in lots
of interventions if we're going to change readmission rates.”

A retrospective study published in Population Health Management in 2011, meanwhile, looked at the impact of a postdischarge telephone follow-up call
on 30-day readmission rates. Among 30,000 patients who were part of a disease management
program, almost 7,000 patients received a phone call from a nurse in the first 14
days after discharge. The peak readmission day was day 2 or 3 after discharge, and
Dr. Greenwald noted that this has been seen in other trials as well. The study found
that patients who didn't receive a postdischarge call had a 30% higher readmission
rate.

This is at best an association, since causality can't be proved in this type of trial,
Dr. Greenwald stressed, noting that his key takeaway from the study was the peak day
for readmissions and what that could mean for the optimal timing of postdischarge
calls.

“If you're waiting until day 14 to make your phone calls... you've already
missed a lot of patients. And if you're going to intervene with phone calls, they
shouldn't be 2 weeks out. Maybe they should be on day 2 if you hope to see an impact,”
he said. “Don't wait until day 14. The horse is out of the barn.”

Dr. Greenwald stressed that he does not advocate abandoning all of these postdischarge
interventions since they may directly help patients who experience other adverse events
related to care transitions, such as medication errors and misunderstanding of treatment
plans.

“No single intervention will likely dramatically move the readmissions needle
alone,” he said. “These types of transitional care interventions should
fit into a bigger menu of interventions you offer patients if you want to work toward
more comprehensive transitions improvements, including reducing readmissions.”

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.